Technological Developments, Exercise Training Programs, and Clinical Outcomes in Cardiac Telerehabilitation in the Last Ten Years: A Systematic Review

Background: Cardiovascular diseases (CVDs) are associated with very high rates of re-hospitalization and mortality worldwide, so the complexity of these pathologies requires frequent access to hospital facilities. The guidelines also emphasize the importance of cardiac rehabilitation (CR) programs, which have demonstrated a favorable effect on outcomes, and cardiac telerehabilitation (CTR) could represent an innovative healthcare delivery model. The aim of our review is to study how technologies used in rehabilitation have changed over time and also to understand what types of rehabilitation programs have been used in telerehabilitation. Methods: We searched randomized controlled trials (RCTs) in three electronic databases, PubMed, Web of Science, and Scopus, from January 2015 to January 2024, using relevant keywords. Initially, 502 articles were found, and 79 duplicates were identified and eliminated with EndNote. Results: In total, 16 RCTs fulfilled the pre-defined criteria, which were analyzed in our systematic review. The results showed that after CTR, there was a significant improvement in main outcome measures, as well as in relation to technological advances. Conclusions: Moreover, compared to center-based rehabilitation, CTR can offer further advantages, with better cost-effectiveness, the breakdown of geographical barriers, and the improvement of access to treatment for the female population, which is traditionally more socially committed.


Introduction
Among chronic diseases, cardiovascular diseases (CVDs) are associated with very high rates of re-hospitalization and mortality worldwide.The complexity of these pathologies requires frequent access to hospital facilities in order to allow multidisciplinary assessments and for the execution of diagnostic tests, resulting in increased direct and indirect costs (loss of work days, travel, inappropriate hospitalizations) [1].Moreover, technological evolution and the experiences gained during the COVID-19 emergency have shown the need to develop new organizational models based on the management of patients with CVD in telemedicine.The use of these technologies allows the patient to be taken in and supervised at home, allowing for a rehabilitation program to be conducted remotely and safely.
In order to reduce hospitalizations and improve the prognosis and the quality of life of CVD patients, especially with heart failure (HF), the recent guidelines [2,3] indicate the need for drug therapy based on four pharmacological "pillars" (Angiotensin-Converting Enzyme inhibitors-ACE inhibitors; Angiotensin Receptor Blocker-ARB; Angiotensin Receptor-Neprilysin Inhibitor-ARNI; mineralocorticoid receptor antagonists-MRA; beta blocker; Sodium-Glucose Cotransporter 2-SGLT2 inhibitors).
However, the international guidelines also emphasize the importance of cardiac rehabilitation (CR), which is an active and dynamic multifactorial process that includes exercise training, cardiac risk factor modification, psychosocial assessment, and outcome assessment [4], which have demonstrated favorable effects on clinical stability, reducing disability and the risk of subsequent cardiovascular events, supporting the maintenance and resumption of an active role in society, and improving survival and quality of life [5].Consequently, CR and supervised training may be considered the fifth pillar in HF treatment [6], and the beneficial effects are evident in patients who adhere to long-term CR programs [7,8].Unfortunately, despite much evidence, supervised training and CR programs are underestimated and underutilized [9], especially due to geographical social barriers and clinical conditions.Long-term participation and adherence to these programs should, therefore, be encouraged and strengthened.Telerehabilitation and mHealth can help to achieve this goal, as suggested in the international guidelines [10].Telerehabilitation is a branch of telemedicine [11] in which information and communication technologies (ICTs) and, in advanced cases, remote-control technologies such as robotics are used to directly provide remote rehabilitation activities [12,13].These technologies also include messaging and calls via telephone and/or the Internet, video conferencing communications between the patient and the healthcare provider, and sensor and telemonitoring systems [1].In the case of telerehabilitation, the systems that allow information to be transmitted are as follows [14,15]:

•
Hardware and software systems that acquire and process signals, images, and data; • Applications that permit the transmission of health information in a bidirectional way; • Dedicated web portals or information technology platforms.
In most cases, telerehabilitation is carried out by providing the patient with videos in which the exercises to be performed are shown.These exercises then can be performed either by videoconference with the therapist ("real-time" telerehabilitation, in which both the healthcare provider and the patient are online) or without supervision (in this case, however, the healthcare provider is "off-line").In some cases, kits containing motion sensors, tablets with customized training software, and other peripherals can be provided to patients [16].Telemedicine and all its components, including telerehabilitation, are recognized as relevant both nationally and internationally, so they are considered a "cultural revolution" [17].This cultural revolution, however, is necessary because of the aging population and the resulting increased incidence of chronic diseases [18].All of the abovementioned indicate the need for innovative healthcare delivery models that support more patient-centered care in order to meet health needs more effectively, reducing current geographic gaps, ensuring a better "experience of care," and improving the efficiency levels of healthcare systems through the promotion of home care and remote monitoring protocols [19].Consequently, the aim of our review is to study how technologies used in rehabilitation have changed over time and also to understand what types of rehabilitation programs have been used in telerehabilitation.

Study Design
This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement [20].

Literature Search
A literature analysis was performed to identify relevant studies in 3 electronic databases, PubMed, Web of Science (WOS), and Scopus, systematically searched from January 2015 to January 2024, taking into account only articles published in peer-reviewed journals, with the following keywords: (Cardiovascular Disease OR Disease, Cardiovascular OR Major Adverse Cardiac Events OR Cardiac Events OR Cardiac Event OR Event, Cardiac OR Adverse Cardiac Event OR Adverse Cardiac Events OR Cardiac Event, Adverse OR Cardiac Events, Adverse) AND (Telerehabilitation OR Tele-rehabilitation OR Tele rehabilitation OR Tele-rehabilitations OR Remote Rehabilitation).Complete search strategies are provided in Appendix A.

Inclusion and Criteria
In this review, we included articles published from January 2015 to January 2024 that were written In English language and had available full texts, along with studies targeting only humans that focused on telerehabilitation of patients with cardiovascular disease.We also defined and applied the following inclusion criteria to identify eligible papers: randomized controlled trials (RCTs) in which adults (≥18 years old) with CVD (i.e., myocardial infarction, angina, heart failure, or after revascularization) attend a cardiac telerehabilitation (CTR) program in comparison with a control group attending usual-care or center-based CR.

Study Selection
Before starting the article selection phase, duplicate records were removed with End-Note.After that, all articles were screened for title and abstract by two independent reviewers who separately selected and discussed conflicts about doubtful cases regarding the inclusion/exclusion criteria.Next, the review authors conducted full-text screening based on inclusion and exclusion criteria to determine the papers' eligibility.During this process, if necessary, a third author resolved potential disagreements via discussion.

Risk of Bias and Quality Assessment of Studies
All the studies included are evaluated using the Cochrane risk-of-bias tool to assess the risk of all types of bias (selection bias, performance bias, attrition bias, reporting bias, and overall bias) [21] (Table 1).After that, all the studies were also checked for the Physiotherapy Evidence Database (PEDro) score to perform a quality assessment.The PEDro score [22] comprises 11 items, with a maximum of 10 points, because the first item (eligibility criteria) does not contribute to total score.Studies with a PEDro score of 9-10 points are considered excellent, studies with a score of 6-8 points are considered good, and, finally, studies with a score of ≤5 are considered poor (Table 2).Among the included studies, 10 are considered poor with a score of 4 or 5; the remaining 6 studies are considered good with a score between 6 and 8. None of the included studies are considered excellent.

Data Extraction
Two of the reviewers (MG, AB) independently investigated the titles and abstracts extracted from the database searches to determine if they fit the inclusion criteria.Disagreements regarding the inclusion or exclusion of a particular manuscript based on the appraisal of its abstract were determined by reaching an agreement or consulting an additional reviewer (MC).Data extraction arrangements were established based on the current literature in the field and the research questions.Extraction of the data was based on essential information according to questions of the current review, such as (a) author, country, and year; (b) study design; (c) population; (d) diagnosis; (e) telerehabilitation; (f) control; (g) technological solutions; (h) outcomes; and (i) results (Table 3).In addition, for quicker reference, Table 4 shows the results of the studies and the qualitative assessment with the PEDro scale.[24] Table 1.Cochrane risk of bias tool for the risk of bias in individual studies.

Overall
Low Risk of Bias High Risk of Bias Unclear Risk of Bias Table 1.Cochrane risk of bias tool for the risk of bias in individual studies.

Overall
Low Risk of Bias High Risk of Bias Unclear Risk of Bias Table 1.Cochrane risk of bias tool for the risk of bias in individual studies.
CG: 6 weeks standard post-PCI care protocol, involving a paper-based and self-study CHD booklet (with advice about management of their lifestyle and risk factors) and a biweekly outpatient review by clinicians.
Physical activity is monitored using remote system (belt strap with sensor, mobile app, servers, web portal).The participants wore the sensor and turned on the application on their smartphone every time they began the exercise training.
6MWT, SF36, FTND, and CDS significantly improved in both groups compared with baseline.
In addition, the improvements in SF36, FTND scores, and 6MWT distance were significantly higher in the IG.Patients of IG wear the accelerometer and transmit their registered activity data weekly to the telerehabilitation center's local server.These data enabled a semi-automatic telecoaching system to provide the patients with feedback, encouraging them to gradually achieve pre-defined exercise training goals.In addition, patients received e-mails and/or SMSs (text messages) with tailored dietary and smoking cessation recommendations.
The addition of cardiac telerehabilitation to conventional center-based cardiac rehabilitation is more effective and efficient than center-based cardiac rehabilitation alone.exercises, with the use of a treadmill, a rowing machine, a multi-fitness station, an elliptical machine, and a cycle ergometer.The subjects exercised for 5 min using each machine, with a 2 min break in between.+ SAT led by a psychologist VR TierOne device (Stolgraf ® , Stanowice, Poland) that comprises a computer dedicated to processing 3D graphics, VR goggles (HTC VIVE PRO, 2017, New Taipei City, Taiwan), enabling the display of high-resolution images with high picture quality (90 Hz), and manipulators that transfer the patient's hand movements into the VR world.Therapy designed to be used with this solution is based on the metaphor of a Virtual Therapeutic Garden where the patient is able to calm down and relax.

Anxiety and depression levels (HADS). Emotional tension level, external stress level, and intrapsychic stress level (PSQ).
Statistically significant differences in the efficacy of rehabilitation between groups were recorded in relation to the level of perceived stress in the sub-scales: emotional tension, external stress, intrapsychic stress, and the generalized stress scale.VR therapy is an efficient and interesting supplement to CR, with proven efficacy in reducing stress levels.Type: Moderate to vigorous aerobic-based exercise Time: A minimum of 30 min (preferably more) most days (at least 5) of the week + personalized, automated package of text messages and a secure website with video messages aimed at increasing exercise behavior.
CG: Usual care with encouragement to be physically active and attend a cardiac club.
HEART program-a personalized, automated package of text messages via their mobile phones aimed at increasing exercise behavior over 24 weeks.They received 6 messages per week for the first 12 weeks, 5 messages per week for 6 weeks, and then 4 messages per week for the remaining 6 weeks (total 24 weeks).
Primary: Physical fitness with CPET parameter pVO2.
A mobile phone intervention was not effective at increasing exercise capacity over and above usual care.The intervention was effective and probably cost-effective for increasing physical activity and may have the potential to augment existing cardiac rehabilitation services.Kinect-RehabPlay project relies on software to monitor and evaluate the rehabilitation exercises, which have to be performed by the user and captured by the Kinect sensor, providing real-time feedback.This system provides a virtual physical therapist performing the exercise and providing indications concerning the quality of execution.The participant is also represented as a second avatar, which interactively follows the physical therapist.The software uses Microsoft Kinect to track individual movements and make a match with a pre-defined pattern.This feature monitored the number of repetitions for each exercise, according to the pre-calculated value, and set it to the individual exercise profile.
Body composition (bioimpedance scale and tape measure), physical activity (accelerometer), eating patterns (Semi-Quantitative Food Frequency Questionnaire), and lipid profile (laboratory tests performed after the termination of the training phase).
The IG1 revealed significant improvements in the waist-to-hip ratio after 6 months and between the baseline and third month when compared with the CG.The IG1 also decreased their ingestion of total fat after six months and increased the high-density lipoprotein cholesterol 3 months after the program's conclusion.

•
Between-group analysis of aerobic capacity was significantly in favor of the IG.

•
During the 12-week program, patients in the IG exhibited better adherence than those in the CG.

•
Self-reported physical activity improved more in the IG than in the CG (all p < 0.01).

Study Selection and Characteristics
Initially, 502 articles were found through database searches on PubMed, WOS, and Scopus; after that, 79 duplicates were identified and eliminated with EndNote.A total of 423 articles were screened for titles and abstracts; after that, 76 papers were selected to be potentially relevant for the present review.Finally, 16 articles were included after full-text screening.This selection process is summarized in the PRISMA flow diagram (Figure 1), and in Table 3, there are the descriptive characteristics of the 16 studies included in the present review, with a focus on the study design, population, diagnosis, intervention, technological solution, measured outcomes, and results.Regarding the diseases assessed, twelve studies are about coronary artery diseases (CAD), one concerned patients with coexisting chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF), one concerned patients who underwent ablation for atrial fibrillation, and two concerned patients with HF.

Study Selection and Characteristics
Initially, 502 articles were found through database searches on PubMed, WOS, and Scopus; after that, 79 duplicates were identified and eliminated with EndNote.A total of 423 articles were screened for titles and abstracts; after that, 76 papers were selected to be potentially relevant for the present review.Finally, 16 articles were included after full-text screening.This selection process is summarized in the PRISMA flow diagram (Figure 1), and in Table 3, there are the descriptive characteristics of the 16 studies included in the present review, with a focus on the study design, population, diagnosis, intervention, technological solution, measured outcomes, and results.Regarding the diseases assessed, twelve studies are about coronary artery diseases (CAD), one concerned patients with coexisting chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF), one concerned patients who underwent ablation for atrial fibrillation, and two concerned patients with HF.

Monitoring Devices
The technological solutions adopted are the most varied and provide for the detection of vital parameters, which are transmitted in real-time by the device that detects them [24,25,27,33,35] or uploaded later by the patients using applications [23,26,34] in or-der to allow the safety of the patients during training and the monitoring of the correctness of the rehabilitation program.Some studies did not involve the detection of vital parameters but only the correct execution of movement by a sensor or with the use of virtual reality in CR [28,37,38].Studies based on virtual reality do not generally aim to improve exercise tolerance but are aimed at anxiety and depression management [29,30].In contrast, the study by Lima et al. [31], which also includes the use of virtual reality, is aimed at improving lung function in post-coronary artery bypass graft (CABG) patients.In the study conducted by Snoek et al. [36], the devices used are able to detect and transmit vital and exercise parameters in real time.Finally, in the 2015 study by Maddison et al. [32], there is no monitoring system; all outcome measures are based on patient's self-reported data.In a 2020 study, on the other hand, the same authors use a very comprehensive system that can directly detect and transmit vital and movement parameters [33].

Intervention
As regards CR programs, the studies included in our review show a wide range of interventions, based mainly on exercise, sometimes accompanied by patient education on the management of risk factors (dietary interventions, cessation of smoking habits, maintenance of an active lifestyle) and counseling interventions for the management of anxiety and depression.These studies also show a wide range of rehabilitation programs in terms of types, intensity, and duration of exercise training.The rehabilitation programs mostly focus on exercise and range from a minimum of 6 weeks with a frequency of three times per week [27] to a maximum of 24 weeks [32,[36][37][38] with a frequency ranging from three to five times per week.
In these studies, the exercise type is moderate-intensity aerobic training [32,36] alone or combined with strength training and stretching [37,38].Three studies involve an 8week home-based exercise program [25,34,35], which, in the case of Piotrowicz et al., 2020 [35], follows an initial 1-week center-based training.In all the above-mentioned studies, combined training, consisting of interval training exercises for strength training with TheraBand or calisthenics in addition to breathing exercises and endurance training (with an intensity ranging from 40 to 80% of the heart rate reserve (HRR)), is used.
Three studies provide a treatment duration of 12 weeks [23,26,33] with a frequency of at least three times or 150 min per week and an indication to be active at least 5 days per week.The exercise programs reported in these papers are based on endurance training at an intensity ranging from 40 to 80% of HRR.Only one study provides a personally tailored 16-week exercise program [24] with an intervention based on both endurance and resistance training, together with patient education about the desirability of maintaining a healthy lifestyle and practicing daily physical activity.
With regard to the studies including the use of virtual reality [29][30][31] associated with exercise training, there are generally only a few sessions, ranging from four to eight, aimed to improve symptoms such as anxiety and depression [29,30], which are often present in people with cardiovascular disease, or to enhance the respiratory pattern in post-CABG patients [31].Despite the wide variety of rehabilitation programs proposed, we report the lack of studies involving exercises to improve flexibility and coordination, and only a few studies have included respiratory exercises.

Primary and Secondary Outcomes
As the primary outcome, most of the included studies consider cardiorespiratory fitness (CRF) assessed with cardiopulmonary exercise testing (CPET), expressed as peak oxygen consumption (VO2 peak) [23,26,32,34,36], maximal oxygen consumption (VO2 max) [33] or as metabolic equivalent of task (MET) [25].Only two studies performed a 6-Minute Walking Test (6MWT) to evaluate the possible effects of CTR on exercise capacity [24,27].The study by Frederix et al. is the only one that performs a cost analysis of CTR compared to center-based rehabilitation [28], while the two studies by Jozwik et al. take into account anxiety and depression levels assessed with the Hospital Anxiety and Depression Scale (HADS) [29,30].
As secondary outcomes in the studies analyzed, we mostly find assessments of physical activity, quality of life (QoL), training adherence, cardiovascular risk factors/laboratory parameters, and anxiety and depression levels.Physical activity is assessed in different ways, i.e., with the Physical Activity Scale for Elderly (PASE) [24], with the International Physical Activity Questionnaire (IPAQ) for the self-reported PA assessment [26,32,36], and finally, with the use of accelerometry data [28,33].
Four studies also report an evaluation of treatment adherence [23,26,33,34] calculated according to the records provided by wearable devices like heart rate zones, accelerometers, and electrocardiogram (ECG) recording devices or through the compilation of exercise diaries.
Finally, a psychological status evaluation was conducted using the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ) [29,30,36].Cai et al. also used the Health Beliefs Related to Cardiovascular Disease Scale and the Exercise Self-Efficacy Scale to evaluate the effects of CTR treatment on their patients.

Discussion
The aim of this review is to highlight how much telerehabilitation has changed since its beginnings.The technologies used in the included studies show a considerable evolution over time from simpler systems, such as text messages sent via telephone, to more sophisticated platforms, which are also equipped with virtual reality.In the studies dated between 2015 and 2018 [24,28,32], in fact, telerehabilitation was mostly designed as text messages, video messages, e-mails, and phone calls made by physiotherapists or nurses aimed to increase the exercise habits of the study participants; even in the 2015 study by Maddison et al., no patient monitoring system was provided [32].
In a 2019 paper published by the same authors [33], however, we also note a strong evolution of the telerehabilitation concept.In this study, in fact, telerehabilitation was delivered via the REMOTE-CR platform, one of the first platforms for telerehabilitation delivery, which was associated with a smartphone and sensors for the detection of vital parameters and movement that transmitted information in real time.Among the older studies, there are two [25,34] that already showed a different concept of telerehabilitation, very similar to how we understand it today, characterized, therefore, by personalized exercise programs monitored via devices integrated with web apps.
In addition to remote monitoring systems and platforms, there are also studies involving the use of virtual reality systems in CR with the aim of treating anxiety and depression and improving breathing quality [29][30][31].Virtual reality in the management of such disorders is actually emerging as a very effective intervention, as it provides users with safe, non-threatening environments where patients can experience a different world and learn how to cope with their anxiety and depression [39].These results are in line with the digitalization process in healthcare and are very encouraging as they go in the direction of overcoming the concept that technologies in rehabilitation deprive the patient of contact with the physiotherapist, on which the therapeutic relationship has always been based, and can therefore constitute a new and equally effective way of treating the patient as a whole [12,40,41].
Another aim of this review is to show what type of rehabilitation program have been mainly used in telerehabilitation and to highlight the effectiveness of telerehabilitation in the treatment of CVD.The rehabilitation treatments used in the included studies are heterogeneous in terms of program duration, single treatment duration, intensity, and type of exercise.In most of the included studies, in line with previous systematic reviews [8,[42][43][44][45], telerehabilitation is able to improve the main outcome measures despite the great variety of the proposed interventions.In the included studies, the treatment designed for the control group is often not described in detail and is rarely supervised by a physiotherapist.On the other hand, when the control group carries out a supervised exercise program, which overlaps with the study group, the results achieved are similar [23,25,35,36] or even lower [32] for the telerehabilitation group.
Most of these studies, however, involve the recruitment of a small sample, like Batalik et al. [23] and Bravo-Escobar et al. [25], so in order to better understand the effects of telerehabilitation, the number of patients recruited should be enlarged, and the exercise programs carried out should be detailed, perhaps even tried to standardize them in relation to pathologies.
However, this contrasts with a study of 850 patients with HF, in which a 9-week full hybrid telerehabilitation program improved pVO2 and QoL but did not increase the percentage of days alive and out of the hospital or reduce mortality and hospitalization over a follow-up period of 14 to 26 months [35].In the study by Maddison et al., 2015 [32], telerehabilitation was ineffective in improving outcomes.Despite recruiting a sample of 171 participants, this study was based on self-reported outcome measures and also did not include monitoring systems, so the own perceptions of training intensity were likely to be lower than the true physiological intensity required to impact exercise capacity.
In the remaining included studies, however, telerehabilitation proved to be an effective and safe intervention in improving patients' CRF expressed as pVO2 [26,34], VO2 max [33], or difference in the meters walked at the 6MWT [24,27]; also, these used together with virtual reality is effective in improving anxiety and depression levels [29,30], selective attention, and conflict resolution ability [38] and in reducing risk factors (i.e., waist-to-hip ratio, BMI, ingestion of total fat) [37], with a better cost-effectiveness ratio than center-based cardiac rehabilitation alone [28].These results are highly encouraging for the implementation of telerehabilitation and telemonitoring systems, especially thanks to the creation of devices that are increasingly easy to use and reliable, which allow rehabilitation to be carried out safely, overcoming geographical and socio-economic gaps.In order to make these technologies more effective and widely used, however, a new approach is needed from both practitioners' and patients' sides.This requires extensive digital literacy and the ability to transfer the traditional therapeutic relationship into a new setting that certainly offers promising possibilities for interaction, as demonstrated by the high patient compliance and adherence to telerehabilitation [46,47], which, however, should be further studied and deepened in the various fields of application [48][49][50].

Conclusions
With this systematic review, we have shown, overall, that CTR can be an advantageous alternative in improving the functional outcome of patients with CVD, especially due to the technological advances we have been assisting in recent years, which allow real-time monitoring and transmission of vital and movement parameters, offering a care experience comparable to traditional center-based rehabilitation.Moreover, compared to centerbased rehabilitation, CTR can offer further advantages, with better cost-effectiveness, the breakdown of geographical barriers, and the improvement of access to treatment for the female population, which is traditionally more socially committed.Furthermore, CTR treatment is safe, can lead to increased levels of participation, and can improve longterm cardiovascular risk management.We also hope that international guidelines will be produced with the aim of reducing the variety of treatment programs and thus improving their effectiveness, and we hope that more studies will be conducted to investigate the long-term benefits of telerehabilitation.

Limitation
This systematic review has several limitations, such as small sample size and compositionin fact, many studies had fewer than 100 participants, and most of the patients were males.In addition, socio-demographic data, cultural and economic level, and place of residence are often lacking.However, such information would be necessary to truly understand the effectiveness and safety of telerehabilitation in the treatment of CVD.Additionally, the included studies were limited to papers written In English papers, and original published research articles were only searched for in three databases.
significant improvements in the waist-to-hip ratio after 6 months (p = 0.033) and between the baseline and third month when compared with the CG (p = 0.041).•IG1decreased their ingestion of total fat (p = 0.032) after 6 months and increased the high-density lipoprotein cholesterol (p = 0.017) 3 months after the program's conclusion.

Figure 1 .
Figure 1.Flow diagram of study selection.

Figure 1 .
Figure 1.Flow diagram of study selection.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Healthcare 2024, 12, x FOR PEER REVIEW Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the risk of bias in individua Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the risk of bias in Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the ris Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk o

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
linding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias)

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Blinding of participants and personnel (performance bias)Blinding of outcome assessment (detection bias)Incomplete outcome data (a rition bias)

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Blinding of participants and personnel (performance bias)Blinding of outcome assessment (detection bias)Incomplete outcome data (a rition bias)

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in

Table 1 .
Cochrane risk of bias tool for the ris

Table 1 .
Cochrane risk of bias tool for the risk of bias

Table 1 .
Cochrane risk o

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.Healthcare 2024, 12, x FOR PEER REVIEW Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias High Risk of Bias Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.Healthcare 2024, 12, x FOR PEER REVIEW Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias High Risk of Bias Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.Healthcare 2024, 12, x FOR PEER REVIEW Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias High Risk of Bias Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.Healthcare 2024, 12, x FOR PEER REVIEW Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias High Risk o Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.Healthcare 2024, 12, x FOR PEER REVIEW Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias H Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias Unclear Risk of Bias Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias Unclear Risk of Bias Healthcare 2024, 12, x FOR PEER REVIEW

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias Unclear Risk of Bia

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias)

.
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias)

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias)

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias High Risk of Bias Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (a rition bias) Selective reporting bias (reporting bias) Overall Low Risk of Bias High Risk of Bias Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individua

Table 1 .
Cochrane risk of bias tool for the risk of bias in

Table 1 .
Cochrane risk of bias tool for the ris

Table 1 .
Cochrane risk of bias tool

Table 1 .
Cochrane risk o

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Overall Low Risk of BiasHigh Risk of Bias Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Overall Low Risk of BiasHigh Risk of Bias Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Overall Low Risk of BiasHigh Risk of Bias Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Overall Low Risk of BiasHigh Risk of Bia Unclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Overall Low Risk of BiasUnclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.
Overall Low Risk of BiasUnclear Risk of Bias

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individua

Table 1 .
Cochrane risk of bias tool for the risk of bias in

Table 1 .
Cochrane risk of bias tool for the ris

Table 1 .
Cochrane risk of bias tool

Table 1 .
Cochrane risk of bias tool for the ri

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 1 .
Cochrane risk of bias tool for the risk of bias in individu

Table 1 .
Cochrane risk of bias tool for the risk of bias

Table 1 .
Cochrane risk of bias tool for the ri

Table 1 .
Cochrane risk of bias tool for the risk of bias in individual studies.

Table 3 .
Descriptive characteristics of the included studies.

Table 4 .
Results of the studies and the qualitative assessment with the PEDro scale.
Event OR Adverse Cardiac Events OR Cardiac Event, Adverse OR Cardiac Events, Adverse (All Fields) #2 Telerehabilitation OR Tele-rehabilitation OR Tele rehabilitation OR Tele-rehabilitations OR Remote Rehabilitation OR Rehabilitation, Remote OR Rehabilitations, Remote OR Remote Rehabilitations OR Virtual Rehabilitation OR Rehabilitation, Virtual OR Rehabilitations, Virtual OR Virtual Rehabilitations (All Fields) #3 Article (Document Type) AND 2015-2024 (Year Published) #4 #1 AND #2 AND #3 Cardiovascular Disease OR Disease, Cardiovascular OR Major Adverse Cardiac Events OR Cardiac Events OR Cardiac Event OR Event, Cardiac OR Adverse Cardiac Event OR Adverse Cardiac Events OR Cardiac Event, Adverse OR Cardiac Events, Adverse #2 Telerehabilitation OR Tele-rehabilitation OR Tele rehabilitation OR Tele-rehabilitations OR Remote Rehabilitation OR Rehabilitation, Remote OR Rehabilitations, Remote OR Remote Rehabilitations OR Virtual Rehabilitation OR Rehabilitation, Virtual OR Rehabilitations, Virtual OR Virtual Rehabilitations #3 #1 AND #2